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IN <br /> . .;:.{ ti, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 web:www.sjgov.org/ehd <br /> .l <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name �" — --- — — - <br /> /, C�'�11 .5' Page of <br /> [..� / . <br /> Facility Adwvsa: - ..ty' — Inspection ate: <br /> OLL <br /> FA#: PR#: Program El e e : <br /> TanklContainer Information <br /> Complete for all sites with'!cumulative aboveground storage of petroleum X1;320 gallons in tanks" and containers`*. <br /> Com fete one box for each tank or each cumulative container product type. <br /> KX lank (2820) El"'Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: gallons Product Type: ,LLLse-2 _ <br /> (per tank or cumulative for c6ntainers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑',Containers (2821) #of Containers: � TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820; 0-Containers (282 1) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: ` gallons Total Capacity for Site: gallons <br /> Comments: <br /> EFID Inspector; Reviewed Date: Entered Date: <br /> By-Initial: V� t�.�-O� By Initial: <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more f petroleum. w <br /> r "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />